DASPA
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Drug & Alcohol Single Point of Access
Authorised Access Only
Online DASPA Referral Form (TPN)
Welcome to the DASPA online referral form for professionals. By completing this form, you are confirming that the person being referred has consented and is aware of the referral being made. Please be as detailed as possible and ensure all details and support needs are correct and accurate before submitting. We may be unable to process the referral if there is limited information and if this is the case, we will endeavour to contact you or the person being referred. If this information cannot obtained, it may result in the referral not being actioned.
File Upload
Relevant paperwork:
If you would like to upload any relevant paperwork ie assessment / risk assessment
Referrer Information
Agreement:
Disclaimer Agreed
Please confirm that the person being referred has given consent. We will collect personal information which could be shared with referral organisations. We may have to contact you for further information if necessary to ensure the referral is forwarded to the correct team.For further information you can visit our Barod website.
Please be aware we will attempt to make contact with the person referred within 3 working days of receiving this form. If we are unable to make contact then we will close down this referral. You can refer back into us via the website or 0300 333 0000:
I understand
Full Name of Referrer:
Please ensure your name and contact information is correct in order so we can contact you if necessary.
What service area do you work in?:
Not Provided...
Alcohol Care Team (within hospital setting)
Barod
CDAT
Community Group/Service
Dyfodol
Education
Employment Service
GP
Health - Community
Health - Inpatient
Housing
Mental Health - Community
Mental Health - Inpatient
Probation
Domestic Abuse Services
Other
Organisation Name:
Email:
Telephone:
Address:
Postcode:
DASPA Referral
Is this referral for :
Cwm Taf
Bridgend
Client Information
For self-referrals, please be aware we will attempt to contact you within 2 working days of receiving your form. If we are unable to make contact then we will close down this referral. You can refer back into us via the website or 0300 333 0000:
I understand
First Name:
Last Name:
Gender:
Not Provided...
Male
Female
-
Agender
Androgyne
Androgynous
Bigender
Cis
Cis Man
Cis Woman
Gender Fluid
Gender Nonconforming
Gender Questioning
Gender Variant
Genderqueer
Intersex
Neutrois
Non-binary
Pangender
Transgender
Transgender (Man)
Transgender (Woman)
Add New...
Ethnicity:
Not Provided...
Asian British
Asian Other
Bangladeshi
Black African
Black British
Black Caribbean
Black Other
Chinese
Indian
Mixed Other/Multiple Ethnic Background
Not Stated
Pakistani
Polish
Portuguese
White Welsh
White British
White Irish
White Other
DOB:
NHS Number:
Address:
Postcode:
Area:
Not Provided...
Rhondda
Cynon
Taff
Merthyr Tydfil
Bridgend
Out of Area
Telephone:
Mobile:
Email:
Substances
Substance use issues:
Please give information of current substance use, pattern of use, particular details of use, details of additional use, provide harm reduction information if required etc
Primary Substance:
Not Provided...
Alcohol
Amphetamine
Anabolic Steroids
Buvidal
Cannabis
Cocaine
Codeine Tablets
Crack
Ecstacy/MDMA
Gabapentin
Heroin
Ketamine
Methadone
NPS
Opiate Other
Pregablin
Solvents
Spice
Subutex
Tramadol
Valium/MSJ/Diazepam
-
No Substance
Add New...
If no substance, add more information into notes above
How Often:
Not Provided...
Daily
2-3 Times a Week
3-5 Times a Week
Weekly
Fortnightly
Monthly
Varies
Abstinent
Binge
Add New...
Amount:
Additional Substances:
Alcohol
Amphetamine
Anabolic Steroids
Buvidal
Cannabis
Cocaine
Codeine Tablets
Crack
Ecstasy/MDMA
Gabapentin
Heroin
Ketamine
Methadone
NPS
Opiate Other
Pregabalin
Solvents
Spice
Subutex
Tramadol
Valium/MSJ/Diazepam
Prenoxad
Risk Management
Risk Management:
Think about risk of harm to self, risk of harm to others, any offences that have included violence, any risk of harm to lone workers? If none write N/A in box
Children Safeguarding Current involvement:
Yes
No
Unsure
Child protection arrangements:
If none write N/A in box . Please give Social Worker name and involvement.
Health Profile
Cwm Taf GP:
Not Provided...
Aberaman Surgery
Abercwmboi Medical Centre
Abercynon Health Centre
Ashgrove Surgery
Brookside Medical Centre
Calfaria Surgery
Castle View Surgery
Cwm Gwyrdd Medical Centre
Cwmaman Health Centre
Cynon Vale Medical Practice
De Winton Health Centre
Dowlais Medical Practice
Eglwysbach Surgery
Ferndale Medical Centre
Forest View Medical Centre
Foundry Town Clinic
Garth View Surgery
Gwaunmiskin Road Surgery
Health Centre University of South Wales
Hillcrest Medical Centre
Hirwaun Health Centre
Horeb Surgery
Maendy Place Surgery
Maerdy Surgery
Morlais Health Centre
New Tynewydd Surgery
Newpark Surgery
Oakland Surgery
Old School Surgery
Pant Surgery
Pantglas Surgery
Parc Canol Practice
Park Lane Surgery
Park Surgery
Penrhiwceiber Medical Centre
Penygraig Surgery
Pontcae Medical Practice
Pontnewydd Medical Centre
Porth Farm Surgery
Practice 1 Kier Hardie Health Park
Practice 2 Kier Hardie Health Park
Practice 3 Kier Hardie Health Park
Rhos House Surgery
Richards Street Cilfynydd
SMSP
St Andrews Surgery
St Johns Medical Practice
Station Yard Pontypridd
Taff Vale Practice
Tegfryn Tonteg
The Health Centre Pontypridd
The Medical Centre Taffs Well
The Surgery Creigiau
The Surgery Elm Road
The Surgery Pontypridd
The Surgery St Davids Street
The Surgery Tonypandy (Llwynypia)
Treharris Primary Care Centre
Troed Y Fan Medical Practice
Tylorstown Surgery
Ynyshir Medical Centre
Ynysybwl Surgery
Meddygfa Glan Cynon Surgery
Pencoed Surgery
Bridgend GP:
Not Provided...
Ashfield Surgery
Bron y Garn Surgery
Bridgend Group Practice
Cwm Garw Practice
Heathbridge House
Llynfi Surgery
Nantyffyllon Surgery
Nantymoel Surgery
New Street Surgery
New Surgery
Newcastle Surgery
North Cornelly Surgery
Oak Tree Surgery
Ogmore Vale Surgery
Porthcawl Medical Practice
Riversdale House
The Medical Centre
The Portway Surgery
The Surgery
Tynycoed Surgery
Woodlands Surgery
-
Are you pregnant:
Yes
No
Unsure
Prescribed Medication:
Include reasons why this is being prescribed and any other relevant information.
Physical and/or mental health problems:
Counselling
Is this a Counselling referral:
Yes
No
Please tick that criteria has been met.:
The person has a Keyworker and will remain open to them while Counselling ongoing
Has had 3 sessions or more with current worker
Issues identified that require counselling
Has not received counselling sessions via Barod in past 12 months
Please confirm all of these in order to confirm eligibility.
Please give brief overview of issues that require addressing :
Please indicate issues to be addressed eg: Bereavement, relationships, ACE's
Support Needs
Please choose the PRIMARY Support Need:
Not Provided...
Advice
ARA Gambling
Barod Under 18 - CYP referral
Brief Intervention
Collaborative Working
Concerned Other
Controlled Drinking
Counselling
Detox
Dyfodol
Groupwork
Harm Reduction
Non referral
Out of Work Service
Physical health assessment
Pre Detox (referral to be made no longer than 8-10 weeks prior to detox)
Psychosocial Intervention
Relapse Prevention
Substance use needing social work intervention (SMSWT)
Substitute Prescribing
Unknown - assessment required
YPDAS - Young Person Drug and Alcohol Service (Tier 3)
Is this a Alcohol Liaison Referral:
Yes
Please tick yes only if referring via Alcohol Liaison Nurse
Is this referral from VAWDASV Team?:
Yes
Will you continue to work with this person?:
Yes
No
Please indicate yes or no and any relevant information in box provided below.
Service User Support Needs / Requirements:
Include here the full support needs of the client/what help are they seeking from the service.
Joint Allocation Meeting - Admin use only
Barod Internal Referrals Only
DASPA Terms
Acknowledgement
The information provided is accurate and the client is aware a referral is being made. I understand that this personal information could be shared with approved referral support organisations. All information will be stored in accordance with our privacy Policy and in line with the requirements set out by the general data protection regulation (GDPR) and the Data Protection Act 1998.
Would you like an Email Confirmation?
If you need email confirmation that your referral has been successfully received then tick this box. Please note that the email will contain the last name of the referral and a unique TPN Reference Number that we will use to refer to this person. This will also be provided on the next screen when you submit these details.